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STAMP HERE (Village of Lincolnshire)

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U.S.A. forms for Village of Lincolnshire

BROWSE VILLAGE OF LINCOLNSHIRE (IL) FORMS

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1 Olde Half Day Road, Lincolnshire, IL 60069
www.lincolnshireil.gov
P: 847-913-2350
F: 847-883-9909
Page 1 of 4
STAMP HERE
AMUSEMENT DEVICE LICENSE
APPLICATION
OFFICE USE ONLY
License #:
LICENSE INFORMATION
Date:
Name of business where device(s) will be located:
License Period Ending:
April 30, 20______
APPLICANT INFORMATION
Person/Organization:
Address:
Contact Name:
Email Address:
Contact Telephone#:
Company Website:
LOCATION INFORMATION
Address of building where amusement device will be located (exact street address):
Telephone #:
Type of business conducted where device(s) will be located:
What is the size of the existing structure on the premises (square footage)?
Number of devices to be operated on premises:
Full description of the location including floor layout, specific floors, rooms, etc.:
Submit an interior diagram of the current/proposed structure with the original application.
Does the applicant own the premises for which the license is sought?
Does the applicant have a lease on the premises covering the full period for which the
license is sought?
If yes, give the following information about the lessor:
Lessor Name:
Telephone #:
Address:
Period covered by
lease:
From:
To:
Options, full particulars:
Yes No
Yes No
Amusement Device License Application – Village of Lincolnshire, IL – Police Department
1 Olde Half Day Road, Lincolnshire, IL 60069
www.lincolnshireil.gov
P: 847-913-2350
F: 847-883-9909
Page 2 of 4
PERSON(S) WITH MANAGING CONTROL OF APPLICANT
(FOR NON-INDIVIDUAL APPLICANTS)
Full Name:
Date of Birth:
Residence Address:
Telephone #:
Driver’s License #:
State of Issuance:
Full Name:
Date of Birth:
Residence Address:
Telephone #:
Driver’s License #:
State of Issuance:
Full Name:
Date of Birth:
Residence Address:
Telephone #:
Driver’s License #:
State of Issuance:
Full Name:
Date of Birth:
Residence Address:
Telephone #:
Driver’s License #:
State of Issuance:
Full Name:
Date of Birth:
Residence Address:
Telephone #:
Driver’s License #:
State of Issuance:
Full Name:
Date of Birth:
Residence Address:
Telephone #:
Driver’s License #:
State of Issuance:
Full Name:
Date of Birth:
Residence Address:
Telephone #:
Driver’s License #:
State of Issuance:
Full Name:
Date of Birth:
Residence Address:
Telephone #:
Driver’s License #:
State of Issuance:
Amusement Device License Application – Village of Lincolnshire, IL – Police Department
1 Olde Half Day Road, Lincolnshire, IL 60069
www.lincolnshireil.gov
P: 847-913-2350
F: 847-883-9909
Page 3 of 4
OWNER/SUPPLIER OF DEVICES
Name:
Telephone #:
Address:
PRIOR VIOLATIONS
Has any person listed on the application ever been found guilty of a gambling offense or
of any violation of any State Statute or local ordinance related to taxes or the commission
of any act of moral turpitude?
Has the applicant ever had a similar license revoked or suspended by any municipality?
Yes No
Yes No
If you answered yes to any of the above, please give full particulars including dates and locations of
offenses.
AFFIDAVIT
• By the signing of the application, the applicant agrees to and hereby authorizes the Village of Lincolnshire
and its agents to conduct whatever investigation that may be deemed necessary to confirm the above
indicated facts, or otherwise to confirm that the applicant is lawfully permitted to obtain An amusement
device license under the amusement device provisions of the Lincolnshire Village Code (as amended from
time to time), or other ordinances of the Village of Lincolnshire and the laws of the State of Illinois.
• Any misrepresentation, omission or false statement on this application or in regards to any information
provided during the application process, shall constitute grounds for the termination of any further
consideration of the application or in the rejection of the application. If any such misrepresentation,
omission or false statement, as mentioned above, is discovered after the application for an amusement
device license has been authorized, and an amusement device license issued by the Mayor and board of
Trustees of the Village of Lincolnshire, said misrepresentation, omission or false statement shall
constitute grounds for the immediate revocation of said amusement device license.
• Approval of application of license/permit shall not be held to permit or be an approval of any violation of
the provisions of the Lincolnshire Village Code.
STATE OF ILLINOIS
COUNTY OF LAKE
The undersigned swear (or affirm) that the sole proprietorship, partnership, or
corporation in whose name this application is made, will not violate any of the
ordinances of the Village of Lincolnshire, or the laws of the State of Illinois or of the
United States of America, in the conduct of the place of business described herein and
that the statements contained in this application are true and correct.
For Individual or Partnership sign here ________________________ Individual / Partner
________________________ Partner
For Corporation, sign here ________________________ President
________________________ Secretary
Subscribed and sworn before me this _______ day of ___________________ , 20 ______ .
_____________________________
Notary Seal Notary Public
Amusement Device License Application – Village of Lincolnshire, IL – Police Department
Device Inventory
Address: _____________________________________
MANUFACTURER
MODEL OR
TRADE NAME
SERIAL NUMBER
DECAL
NUMBER
DATE
LICENSED
LOCATION ON PREMISES
OF AMUSEMENT DEVICES
1.
2.
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Page 4 of 4
Amusement Device License Application – Village of Lincolnshire, IL – Police Department
1 Olde Half Day Road, Lincolnshire, IL 60069
www.lincolnshireil.gov
P: 847-913-2350
F: 847-883-9909
Automatic Amusement Device License
Application Instructions
• Applications for an Automatic Amusement Device License must be made to the Lincolnshire Police
Department on the application form furnished.
• Applicants filing an application for an Automatic Amusement Device License will need to complete
all sections of the application and remit a $250.00 fee for the license and a $75.00 decal fee for
each device.
• The following information must be submitted along with an original application:
1. A copy of an interior diagram depicting the location of each device.
2. An inventory of the device(s) for which the applicant is seeking a decal.
• Return the completed applications with your payment to cover the license fees.
• The Automatic Amusement Device License section of the Lincolnshire Village Code can be accessed
through the Village web site.
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STAMP HERE (Village of Lincolnshire)

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Completed 23 January 2021

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